HomeMy WebLinkAboutBuilding Permit #670 - 285 CHESTNUT STREET 6/4/2009Nvfi ►y
BUILDING PERMIT OftgilD ,6'9q,
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TOWN OF NORTH ANDOVER 4 `
APPLICATION FOR PLAN EXAMINATION
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Permit NO: Date Received - 74pDRATfD
Date Issued.` �SSgcHus��
IMP��OyyRTANT: Applicant must complete all items on this page
LOCATION La - CA
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PROPERTY OWNER n1 Print
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Print
MAP NO: CC PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes n
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
e air, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
VL
Identification Please Type or Print Clearly)
OWNER: Name:
CONTRACTOR Name:
Address:
Phone:
Supervisor's Construction License: Exp. Date:
Home Improvement License:
ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $���y -� FEE: $ 0
Check No:
G Receipt No.: Qa0
NOTE: with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Ownerure of contractor
Location Cpi �;- C ll -e4 iw -r— -S�/
No. (0-7-0 1 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision:
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Dor. INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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Insurance Company Name -
0 r-Y
ame:olicy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/state/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dale).
Failure to secure eovetage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fine UP to $1,500,00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP Wd a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ORK ORDER an
Investigations of the DIA for insurance coverage verification.
I do heresy certify under thheePairs and penalties ofPerjrvy that the information provided above is tme r com[
I .1'i� ( I—i i
Ofj<icial use only Do not write in this area, m be completed by rill, or town ociaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health Z Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing inspector
6. Other
11 Contact Person• Phone #:
The Commonwealth of Massachusetts
1-4
61`=.(
Department of industrial Accidents
Office of Investigations
1� ;'
600 Mashington Street
Boston, MA 02111
www nzassgov/dia
Workers' Compensation Iasiu-anee Affidavit: Sunders/Contractors/Eiectricians/Piumbers
Applicant Information
Please Print Le-ibi
Nar a (Business/Orpnization/individual): �5 �� �1�•�
Address: ,
r
City/State/Zip:_ AVO
(//�A Phone #: .
re you an employer? Cheekthe appropriate box:
I t9tn a employer with
F2.
4. ❑ I am a Q T� ofProject (required):�ertaral contractor and Iemployees
(full and/orpart-time).*
I am .a.sole proprietor or
have hired the sttb-cotrisacors6. ❑New coristrvctionQ
Iisted
partner-
ship and have no employees
on the attached sheet S 7• Q Remodeling
These sU&contractors have g Q Demolition
working for me in any capacity.
[No workers com .insurance
' P
worke=rs' comp. insurance.
5. 9• ❑ Building addition
❑ We are a corporation and its
sired.]
m a homeowner doing all work
3 17YVself,
officers have have exercised their 10 Q Electrical repairs or additions
right of exemption per MGL 11.❑ Plumbing repairs
[No•workers' comp.
insurance required.] t
or additions
c. 152, § 1(4), and we have no
-employees. [No workers' 12.[] Roof repairs
comp. insurance required.] 13.7Other
*Any
*Airy appiicant that checks box! # I must also fill out the section bciow showin their workers oom
who submit this affidavit indicating theyam doingall work g � ��10s Policy information
;Contractors then him outside ontraetor
most submit a new affidavit indicetiog eucfr
that check this box mustaneched an add iossi sheet showing. the name of the sub �d ntmetors and their workers' cam" Poli;, ir.6mmdon
e aer an employer that is providing workers' compensation insurance or
informadom } NV employe=. Below is the po&y mid jolt site
Insurance Company Name -
0 r-Y
ame:olicy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/state/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dale).
Failure to secure eovetage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fine UP to $1,500,00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP Wd a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ORK ORDER an
Investigations of the DIA for insurance coverage verification.
I do heresy certify under thheePairs and penalties ofPerjrvy that the information provided above is tme r com[
I .1'i� ( I—i i
Ofj<icial use only Do not write in this area, m be completed by rill, or town ociaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health Z Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing inspector
6. Other
11 Contact Person• Phone #:
Information a lad Instructions
Massachusetts General Laws chapter 152 requires all emp Ioyms to provide workers' compensation for their empioyees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the'foregoing engaged in a joint enterprise, and includirag the legal representatives of a deceased employer, or the
receiver or 1r utee of an individual., partnership, association► or other legal entity, employing employees. 'However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, 925C(6) also states that "every state or local licensing agency shale withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.of compliance with the insurance coverage required."
Additionally, MOL chapter 152, §25C(7) states "Neither tide commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public woric until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation, affidavit oomplr--tely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) grad phone numcer
number(s) along with their tificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. Ifan LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage.. Also lv a sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the .application for the permit or license is being requested, notthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you are requimd to obtain a workers'
compensation policy, please call the Department at the number. listed below. Self. -insured companies should enter their
self insurance'Iicense number on &e'appropriateline.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennit/license number which %,ill be used as a reference number. In addition, an appiicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of -the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said porson is NOT required to complete this affidavit
The Office of lnveAiWions would lflm to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of F-ndrastiial Accidents
Office of Investigations
600 Washington Street
Boston, 1vIA 02111
TeL # 617-7274900 exit 406 or 1-8.77-MASSAFE
Fax # 617-727-7742
Revised 5 -26 -US www,mass_govidia
Gerald A Brown
Inspector of Buildings
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
DATE:
JOB LOCATION:
Number Stmt Address
Telephone (978) 688-9545
Fax (978)688-9542
HOMEOWNER -R lM F(lft)
Name Home Phone Work Phone
PRESENT MAILING ADDRESS_"J �7-
City Town
Zip Code
VS
The current exemption for -homeowners- was extended to include owner -occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hue who does not possess a license, provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended
to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection Procedures and requirements and that he/she will fly with said procedures and
requireme�.
APPROVAL OF BuiLDING OFFICIAL
Raviud 10.2005
Form Homeowners E=Wfioo
i-3OARD OF \PPF: V. S (,'3R ,)541 C0NSERV.1T'I()N F,y8-9530 HE-UMi 488-95.10 PLANNING f 8&9535